NCC222208_FRO Submitted_20220615

c° SOIL EROSION and SEDIMENTATION CONTROL
7NATURAL
'`Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
URC�S
FINANCIAL RESPONSIBILITY/ OWNERSHIP FORM
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A �
1. Project Name L--(5 L`'' i' Ul°S � _ i - L and Cyr ilaleAm 'Pa at � 5
2. Location of land -disturbing activity: titu 35. 4� Longitude ' ZS 01y
Parcel Identification Number (P ) U r- Watershed Area ` iU 1044 So
Highway/Street Address AW kl.nyeo lE krl I L—direlafm AJe, Oq2 J U�j y 51
3. Approximate date land -disturbing activity will commence: —� 3 v a� I UNW
_ INN 53
4. Purpose of development (residential, commercial, industrial, institutional, etc.): )Zesiderrha Io qL 5 ,2
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9, I _5
I� uG )��! N Siv
6. Amount of fee enclosed: $ CO00 ._ . The Standard Permitting application fee of $200.00 per acre 1bgL15
(rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800). The Express 1694511
Permitting application fee is a dual charge. The normal fee of $200.00 per acre (rounded up to the next acre) is 169 L4 5 6
assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight 104 N5-9
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name & I w Lznct E-mail Address l Clod ZG (`1 be I Uoth , Y)e+
Telephone Cell #?UA" q'73 4ZG/D Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
f _L1nr'i Constructs ors . lac -
Name
i -'D NI v r ate H i 11 Lal1e.
Current Mailing Mdress
1_t,3A
City State Zip
`7()H - t-I n 3
Telephone
Current Street Address
City
State
Fax Number
Zip
10. Deed Book No .�20 Page No.'9 1 LD most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
City State Zip
Telephone Fax Number
Current Street Wress
City State Zip

14
°�-c° A SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
RrNATURAL 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
Part B
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsible parties on an attached sheet):
-dnd �b ns`I wt✓ i c� j,� r' . Viand Z C' u scut h . ne+
Name E-mail Address
3 r1 ( -n C k Lane,
Current Mailing Addr ss Current Street Address
Linc ointon NG 2e(j 2
City State Zip
Telephone
City State Zip
Fax Number
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name,
attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone Fax Number
State Zip
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant
Current Mailing Address
City
State Zip
ual contact pe►-son (type or print) Telephone Fax Number

w ° x °� SOIL EROSION and SEDIMENTATION CONTROL
N Lincoln County Natural Resources Department
NAT.ML 115 West Main Street, Lincolnton, NC 28092 704-736-8601 Fax: [phone]
RC5oURC[5
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
IBC , l Q
Name of Person or Firm Name of Person or Firm
e 1 \ La
Current Mailing A41ress Current Street Address
Lllyc 2fJ�(D.
City State Zip City State
& 1
Individual c tact person (type or print) Individual contact person (type or print)
Telephone 00 "�-t9, ) - Z2-40 Telephone
Fax Number
Fax Number
Zip
The above information is true and correct to the best of my knowledge and belief and was provided by me under
oath (This form must be signed by the Financially Responsible Person if an individual or his attorney -in -fact, or if not an
individual, by an officer, director, partner, or registered agent with the authority to execute instruments for the Financially
Responsible Person). I agree to provide corrected information should there by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
Type or na e I itwr or Authority
Signature Date
------------------------------------------------------------------------------------------------------------------------------------------------
r
a Notary Public of the County of II Y1a )n
State of North Carolina, hereby certify that 4JI1114 U i I Ity U1 appeared personally before
me this day and being duly sworn acknowledged that th a'bboove form was executed by him.
Witness my hand and notarial seal, this Z day of �J 2
-
`,.�'��� T. RU`'�.,, a
�- Seal • •. � � �
My commission expires Za
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